Lung cancer and Melanoma Flashcards

1
Q

State the 4 most common symptoms of lung cancer

A
  • Persistent unexplained cough lasting more than 3 weeks
  • Haemoptysis
  • SOB
  • Weight loss
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2
Q

State some investigations for suspected lung cancer

A

Initial:
- Bloods
- CXR

Further:
- Biopsy for histology (CT-guided, bronchoscopy or thoracoscopy if pleural effusion)
- Staging CT
- Evaluate fitness and lung function tests (helps predict whether surgery will leave patient breathless after)

Followed by MDT discussion

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3
Q

State some bloods to do for suspected lung cancer

A

Calcium is VERY important - most common sign found in lung cancer
- FBC
- U&Es
- Calcium (most common sign)
- LFTs (check for liver mets)
- INR (check for liver mets)

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4
Q

State some histology options for biopsy in lung cancer

A

Choose based on whether the tumour is central, peripheral or peri-bronchial/para-tracheal

  • Sputum cytology
  • Bronchoscopy
  • EBUS-TBNA (specific type of bronchoscopy)
  • CT guided lung biopsy
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5
Q

State some investigations for malignant pleural effusion

A
  • Bloods (same as standard suspected lung cancer)
  • US guided aspirate and cytology/microbiology

If cytology from US guided aspirate if negative, need to do a medical thoracoscopy

Pleural effusion cancer cannot be cured

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6
Q

State an incidental nodule and why is it significant in lung cancer

A

“blob” in the lung >5mm

Significant as it may represent early cancer - if > 20mm then 50% chance of developing cancer

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7
Q

State how MSCC (metastatic spinal cord compression) can present and how to manage

A

Presentation:
- Upper motor neurone signs
- Back pain (progressive, unremitting, worse on straining)
- Localised tenderness over affected area
- Urinary retention / constipation
- Sensory loss in saddle area

Management:
- Urgent MRI with discussion with spina surgeon and oncologist
- Urinary catherisation
- High dose steroids (IV or PO) e.g. oral Dexamethasone 16mg
- Radiotherapy / surgical decompression (depending on prognosis)

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8
Q

State how manage hypercalcaemia in lung cancer

A
  • IV fluids for around 48 hours (dilute calcium)
  • Pamidronate infusion over 30-60 mins (drives Ca back into cells) (Zoledronate in breast or prostate cancer)

This will control calicum for around 6 weeks - in time to manage underlying condition

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9
Q

State how SVC obstruction can present, suggested imaging and how to manage (acute and long term)

A

Presentation:
- Localised oedema of the face and upper extremities
dyspnoea
- Dyspnoea
- Cough
- Facial plethora
- Distended neck/chest veins
- Hoarseness of voice

Suggested imaging:
- Chest x-ray
- CT scan (staging CT helpful)

Acute management:
- Sit patient upright
- Oxygen
- Analgesia if needed
- Dexamethasone to reduce swelling and oedema

Definitive management:
- Urgent CT staging and biopsy to determine cause
- Stent the SVC
- Radiotherapy (if caused by non-small cell)
- Urgent chemo (if caused by small cell)

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10
Q

State some causes of hyponatraemia in lung cancer and how to manage acutely

A

Paraneoplastic syndromes:
- Cushing’s syndrome
- Hypertrophic pulmonary osteoarthropathy
- Lambert-Eaton syndrome
- SIADH
- Trousseau’s syndrome

Last less than 3 months :(

Management:
- Admit to hospital
- Fluid restriction
- Demeclocycline
- Tolvaptan

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11
Q

State some oncological emergencies in lung cancer

A
  • MSCC
  • Hypercalcaemia
  • SVC obstruction / compression
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12
Q

State how to manage headache and brain mets

A

1) CT scan
2 ) Followed by MRI brain

  • Start Dexamethosone 4mg bd
  • Can give stereotactic radiosurgery (SRS) if < 5 brain mets
  • If seizures, give Keppra

Shouldn’t be driving!!

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13
Q

State the pathway for someone presenting with suspected lung cancer from an abnormal CXR

A
  • Triage by LC Physician - decide stage/investigations
  • Urgent CT
  • OPD appointment, see patient in clinic (LC Physician & Specialist Nurse) – Break Bad News, explain diagnostic plan
  • Discuss at LC MDT – decision on treatment modality and update patient
  • Patient seen by appropriate MDT specialist to commence treatment
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14
Q

State the time limits for a patient with suspected cancer

A
  • No more than 62 days (2 months) from the date the hospital receives an urgent suspected cancer referral and the start of treatment
  • No more than 31 days from the meeting at which you and your doctor agree the treatment plan and the start of treatment
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15
Q

State some types of lung cancer surgery

A
  • Wedge resection (early disease and small tumour)
  • Lobectomy
  • Pneumonectomy
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16
Q

State the major subtypes of lung cancer

A

1) Small cell (rapidly progressive) = chemo-sensitive

2) Non-small cell:
- Squamous
- Lung adenocarcinoma (mutation driven, not associated with smoking)
- Large cell carcinoma (doesn’t respond well to chemotherapy)

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17
Q

State some characteristics of the major subtypes of cancer

1) Small cell

2) Non small cell
a) Squamous cell
b) Adenocarcinoma
c) Large cell

A

1) Small cell (20%)
- Arise from APUD cells
- Tend to cause paraneoplastic syndromes
- Tend to be more central
- Rapidly progressive
- But respond well to chemotherapy (not to surgery)

2) Non-small cell:
a) Squamous cell (35%)
- Arise from epithelial cells lining airways
- So tend to be more central
- Metastasise later than other types
- More likely to cause lung collapse or blockages
b) Adenocarcinoma (32%)
- Arise from peripheral, mucous secreting cells
- So tend to be more peripheral
- Less associated with smoking
c) Large cell (10%)
- Undifferentiated cancers and tend to lack structure of other 2 types
- Doesn’t respond well to chemotherapy

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18
Q

State some changes that could be seen on a chest x-ray in a patient with suspected lung cancer

A
  • Visible mass
  • Mediastinal widening
  • Hilar lymphadenopathy
  • Lobar collapse
  • Pleural effusion

However none of the findings of diagnostic, requires histology and staging CT scan

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19
Q

State the 4 types of radiotherapy methods for lung cancer and when they are used

A

1) Radical - high dose with curative intent

2) SABR - focussed for smaller cancer with curative intent

3) Palliative - small dose for symptom control only

4) Intraluminal brachytherapy - if cancer is growing into central airways

20
Q

State some palliative interventions for lung cancer

A
  • YAG laser
  • Cryotherapy
  • Diathermy
  • Brachytherapy
  • Bronchial stents
21
Q
A
22
Q

State the NICE guidelines for lung cancer referral

A

> 40 with 2 or more of the following:
- Cough
- Fatigue
- SOB
- Chest pain
- Weight loss
- Appetite loss

If ever smoked - only need 1 of the above

Refer for a 2WW chest x-ray

23
Q

State what pathway would the following scenarios cause
- >40 with haemoptysis
- CXR findings suggest lung cancer

A

2WW appointment to see chest physician

24
Q

State the difference between EBUS, bronchoscopy alone and percutaneous CT-guided biopsy

A

EBUS - samples the lymph node (or multiple depending on results of PET-CT scan)
Bronchoscopy alone - samples cancer itself (cancer must be invading into bronchiole)

Use EBUS if there is lymph node involvement, if not need to do bronchoscopy alone

CT guided biopsy - samples cancer itself, especially for peripheral tumours (more invasive but good if further out)

25
Q

State the risks and benefits of EBUS

A
26
Q

State the risks and benefits of bronchoscopy alone (biopsy)

A
27
Q

State the risks and benefits of percutaneous CT-guided biopsy

A
28
Q

State 3 main subtypes of melanoma

A

1) Superficial spreading (70-80% of melanomas)
2) Nodular
3) Lentigo

29
Q

Outline the 3 main subtypes of melanoma
1) Superficial spreading
2) Nodular
3) Lentigo

A

1) Superficial spreading (70-80% of melanomas)
- Relatively slow growing in early stages (should be readily detectable)
- Irregular in shape
- Irregular in colour
- Progressively changing
Also subtype of ‘spitzoid’ melanoma (which is ‘new’, ‘juicy’ and more regular in shape)

2) Nodular
- Faster growing
- Raised nodule
- Slightly or deeply pigmented
- Often friable / vascular

3) Lentigo
- Precursor of melanoma, in situ
- Very slow growth
- Associated with chronic sun exposure

30
Q

Melanoma - state the following:
- Pathophysiology
- Location (where are they found on the body)
- Risk factors
- Presentation
- Investigation
- Management

A

Pathophysiology:
- Aggressive form of skin cancer, arising from abnormal melanocyte growth
- Presents as changes to / new pigmented lesions on the skin

Location (where are they found on the body)

Presentation - ABCDE:
Asymmetry
Border is irregular
Colour variation
Diameter >6mm
Evolution / elevation

Investigations:
- Excision biopsy
- Sentinel lymph node biopsy (if the Breslow thickness is >1mm)
- Further imaging e.g. PET CT if suspicion of mets

Management:
- Surgical excision (margin determined by Breslow thickness)
- Some additional treatments if needed e.g. radiotherapy, immunotherapy or BRAF inhibitors (do immunotherapy first then BRAF if positive)

31
Q

State some risk factors for melanomas

A
  • Family history or prior personal history of melanoma
  • High levels of sun or UV exposure
  • Fitzpatrick type I or II
  • Immunosuppression
  • Older age / male
  • Smoking
32
Q

Actinic (solar) keratoses - state the following:
- Pathophysiology
- Location (where are they found on the body)
- Risk factors
- Presentation
- Management

A

Pathophysiology:
- Dysplastic (precancerous condition)
- Lesions which are yellowish or erythematous, ill-defined, irregularly shaped, small, scaly macules or plaques
- Can potentially progress into squamous cell carcinoma (SCC)

Location:
- Occur at sun exposed sites e.g. head, ears

Risk factors:
- Fair skinned
- Outdoor occupation
- Older age

Presentation:
- Scaly rough patch, on erythematous background
- Feels like sandpaper

Management:
- Sun protection e.g. hats, sunscreen
- Cryotherapy (liquid nitrogen)
- 5-FU cream or Imiquimod
- Surgical excision / curettage and cauterisation
- Photodynamic therapy

33
Q

Bowen’s disease - state the following:
- Pathophysiology
- Location (where are they found on the body)
- Risk factors
- Presentation
- Management

A

Pathophysiology:
- Also known as SCC in situ
- Dysplastic (precancerous condition) changes in the epidermis
- Non-itchy lesions, fixed, erythematous patches of skin
- Can potentially progress into squamous cell carcinoma (SCC)

Location:
- Commonly occur on lower legs of women
- Can occur on hands and nails

Risk factors:
- HPV
- Exposure to oils
- Fair skinned
- Outdoor occupation
- Older age

Presentation:
- Often multiple lesions
- Non-itchy, fixed, erythematous patches of skin
- Slightly scaly
- Don’t respond to moisturisers or topical steroids

Management:
- Sun protection e.g. hats, sunscreen
- 5-FU cream or Imiquimod
- Surgical excision / curettage and cauterisation
- Photodynamic therapy
Cryotherapy - less good as wounds take a long time to heal

34
Q

Basal cell carcinoma - state the following:
- Pathophysiology
- Location (where are they found on the body)
- Risk factors
- Presentation
- Management

A

Pathophysiology:
- Most common non-melanoma skin cancer
- Malignant tumour of the keratinocytes within the epidermis
- Can be locally invasive, but very rarely metastasises (often in larger tumours)
- Common have multiple tumours - important to check whole of skin
- Associated with higher risk of other skin cancers (e.g. melanoma and SCC)

Location:
- Commonly sun-exposed areas of the face (commonly temples)

Risk factors:
- Fair skinned
- Childhood sunburn
- Family history
- Immunosuppressed

Presentation:
- Shiny, pearly nodule (sometimes a umbilical, necrotic or ulcerated center)
- Telangiectasia
- Appear translucent (don’t produce a lot of keratin)
Commonly can have multiple nodules

Management:
- Excise tumour (Moh’s micrographic surgery) if high risk e.g. near eyes, ill defined etc.
- Radiotherapy in poor surgical candidates
- Other options for smaller lesions e.g. curettage and cautery
Future = sun protection e.g. hats, sunscreen

35
Q

Squamous cell carcinoma - state the following:
- Pathophysiology
- Location (where are they found on the body)
- Risk factors
- Presentation
- Management

A

Pathophysiology:
- 2nd most common non-melanoma skin cancer
- Locally invasive malignant tumour of epidermal keratinocytes
- Metastasis is uncommon (higher risk if large and poorly differentiated)

Location:
- Commonly sun-exposed areas of the face

Risk factors:
- Fair skinned
- Outdoor occupation
- Older age
- Sun exposure
- Chronic inflammation / actinic (solar) keratosis
- Immunosuppression

Presentation:
- Warty tumour (keratin) upon a fleshy base
- Can appear as ulcerated nodules if more advanced (poorer prognosis)

Management:
- Excise tumour if high risk e.g. near eyes, ill defined etc. (consider Moh’s surgery if recurrence of previous cancer)
- Radiotherapy in poor surgical candidates
- Other options for smaller lesions e.g. curettage and cautery
Future = sun protection e.g. hats, sunscreen

36
Q

Outline the differences between a lesion of BCC and SCC

A

Both tend to appear on sun-exposed areas

Basal cell carcinomas:
- Shiny and pearly
- Don’t tend to be painful or bleed
- More slower growing

Squamous cell carcinomas:
- Irregular, ill-defined red nodule with scale and ulceration
- Can be painful or bleed
- More faster growing

37
Q

Outline what Mohs micrographic surgery is and when it is used

A

Tissue is excised during surgery and examined under a microscope in real time
This is to ensure that all the cancerous cells are removed but the maximum amount of healthy tissue is preserved

This is done especially if :
- Area is ill-defined macroscopically
- Area is in need of preservation e.g. ear lobe or nose

38
Q

State the general prognosis for squamous cell carcinoma

A

5 year survival of 99% (if detected early)

39
Q

State how brain metastases secondary to melanoma can be managed

A
  • Steroids (symptom management)
  • Immunotherapy
  • Surgery (less than 3 lesions)
  • Stereotactic radiotherapy of surgery not an option (don’t tend to do whole brain radiotherapy)
40
Q

Outline common sites of metastasis for lung cancer

A

LBBA

Liver
Brain
Bone
Adrenal glands
+ lymph nodes

41
Q

Outline common sites of metastasis for melanoma

A

LLBB

Lung
Liver
Brain
Bone
+ lymph nodes

42
Q

List some causes of pneumonitis in patients undergoing lung cancer treatment

A
  • Radiation
  • Immunotherapy / targeted therapies
  • Chemotherapy e.g. Bleomycin, Methotrexate
  • Tumour itself
43
Q

Outline the presenting symptoms and signs of pneumonitis

A
  • Dyspnoea
  • Chest pain (pleuritic)
  • Cough
  • Low-grade fever
  • Reduced O2 sats
44
Q

What investigations are useful in diagnosing pneumonitis and results would it show?

A

Chest x-ray:
- Airspace opacities
- Pleural effusions
- Atelectasis

Non contrast HRCT:
- Ground-glass opacities
- Airspace consolidation

Bronchoscopy

45
Q

How is pneumonitis managed in lung cancer treatment?

A
  • Consider pausing / halting treatment therapy e.g. immunotherapy
  • Steroids e.g. IV Methylpred then oral Prednisolone (reduce inflammation)
  • Ventilation / ITU may be required if severe pneumonitis
  • Consider antibiotics if suspicion of infection